Category: Hospital Fraud

Prevent medical insurance fraud cases from robbing people in need of the care they deserve.

Medical insurance fraud cases don’t represent a victimless crime, and it doesn’t just affect big corporations. These types of crimes are directly responsible for shrinking benefits and higher costs. People who need insurance coverage get dropped every time insurers make adjustments. Anyone has the ability to make a difference by stopping insurance fraud in its tracks. Depending on the circumstances, doing so might add a few zeros to your bank balance.

Most Common Types of Healthcare Insurance Fraud

Billing for care never the professional didn’t provide

Misrepresenting details of care

Providing unnecessary care or prescribing unnecessary medication

Incorrectly diagnosing patients to substantiate expensive treatments

Failure to collect copayments

Offering kickbacks

The Most Common Problems

In over half of fraud cases, health care providers bill for services they never performed. The most worrisome cases involve multiple patients who many times suffer from some sort of disability. Their impairment makes them vulnerable to fraud or to threats by medical professionals who don’t want them to discuss what is (or rather, what isn’t) going on behind closed doors.

In many cases, patients don’t even see the provider. The visit is simply added to their bill. Offices then falsify patient records — or not. Investigators report that a majority of fraud cases get closed quickly because there is zero documentation to back up their false bills.

Both of these situations can be difficult to pinpoint unless you know a patient well. If you’re an in-home care provider, for instance, you can talk with the patient at length about what happened during their appointment and compare it against the bill. Likewise, if bills are arriving for dates and services the patient wasn’t involved in, there’s sufficient reason to ask more questions.

Misrepresenting Details of Care

When it comes to misrepresentation, many healthcare providers tell themselves they’re doing the right thing. They fudge dates or treatment types to ensure someone is paying for procedures their patients need. They might change locations or staff names around to ensure payments get spread around. People who benefit appreciate the results, so they rarely say anything to put a stop to it. However, most fraudsters don’t stop at simply helping their patients. They help money into their own pockets.

Take, for instance, the practice of changing dates. Clinics might perform two or three types of treatment during a single visit. The bill would include an office fee, exam fee, and specific treatment expenses. An office might choose to split this bill into three visits, each with their own office and exam charges.

Other Types of Fraud Can Hurt Patients

Other types of misrepresentation are dangerous for patients. For example, a fairly common type of fraud involves claims for therapy or treatment happening onsite when the patient performs it at home on their own. This can range from physical therapy to injections and wound care. Many of these practices aren’t covered by insurance because they’re not considered safe.

In other cases, doctors sign off on care that’s provided by staff without proper training. These kinds of clinics often bring in legitimate health providers to act as supervisors without letting them in on the details. Once they realize they’re dealing with an illegal operation, they might be too afraid of repercussions to come forward.

If bills come to your home detailing treatment performed on the wrong dates, in the wrong locations or in different ways than they’re delivered in reality, ask your health professional for an explanation. Medical billing is complicated and human error might have played a role, but there’s likelihood of fraud if it keeps happening.

Other types of fraud are becoming less common, but they are some of the most damaging in the industry.

How Fraud Robs Patients in Need of Critical Care

Throughout the 90s and early 2000s, one of the most common types of medical insurance fraud was writing bad prescriptions. Patients who didn’t need heavy-duty painkillers would get them, sell them and pay the doctor a little extra. Those scams are much less prevalent today because the government has gone out of its way to catch them. Unfortunately, it highlights exactly how fraud can cost patients in need.

The majority of community healthcare centers – facilities where low-income families go to receive the care they cannot afford anywhere else – do not prescribe pain medication. Urgent Care units won’t either. It takes an expensive trip to a family doctor or specialist to receive adequate pain management, and even then, a doctor might refer a patient to a specialty office. Few doctors will deal with the scrutiny of prescribing those kinds of drugs, even when they have a patient who would greatly benefit from taking them.

Access to quality, necessary care is at stake, and anyone can help secure it. If you’ve seen a business or health provider engaging in fraud, you have the ability to stop it.

Hospice fraud has taken a hairpin turn into the hard-to-prosecute, harming honest hospice care providers, the government and whistleblowers alike.

In our evolved and humane culture, it’s only right that our elderly and terminal patients have a pleasant, government-supported place to spend their final days. Yet in the wake of the Affordable Care Act, it seems many hospice care centers have chosen to capitalize on the unprecedented potential of Medicare payments by filing claims that result in hospice fraud.

Among the companies under the microscope recently are Palliative Services of the Treasure Coast and Horizons Hospice. Both of them paid millions of dollars in fines for false Medicare claims, explains Home Health Care News. Given this, the U.S. Department of Health & Human Services Office of Inspector General is now cracking down on hospice centers. They are more determined than ever to ensure government money gets spent wisely.

Yet the case is not that simple.

A Troubled Trial from the Start

The trial against AseraCare is a perfect illustration of how difficult it may prove to come to a decision over hospice care fraud. Among her various decisions over a several-year period, Judge Karon Owen Bowdre did anything but clarify or streamline the case. Her actions over that time include:

Splitting the case into two separate trials to address a) the fraud allegations and b) to treat the rest of the claims against AseraCare

Assertions she did not provide adequate instructions upfront, leading to the judge overturning the jury’s finding that AseraCare submitted 104 of its 121 claims falsely

Tossing out the case entirely, stating that with the vast disagreement over whether or not a patient is terminally ill, it’s impossible to prove the falsity

Today, the decision rests with the 11th Circuit Court of Appeals, but the timeline is hazy at best, nonexistent at worse.

The result, to say the least, is massive confusion across the industry. Honest providers feel targeted and insecure. They are uncertain how to “ensure” their patients will really live six months or less. On the other hand, dishonest providers are happy to jump at the chance this troubling case provides. Whistleblowers, lastly, feel understandably helpless.

Confusion Persists, but Injustice Doesn’t Have To

Despite the recent claims that prosecuting hospice fraud grows ever more impossible, that’s not the case. Are you are a whistleblower concerned about injustice and misuse of government money? There is a place for you in the courtroom.

Come see us at Bothwell Law Group, where we dedicate all our energy to representing qui tam whistleblowers. A successful claim can mean rewards for you and support of the U.S. government, so don’t wait. Call us at 770.643.1606 today.

Unfortunately, medical malpractice cases occur very frequently.

Considering how many mistakes occur in the medical setting, it’s amazing there aren’t more medical malpractice cases. Johns Hopkins Medicine reports that medical errors cause more than 250,000 deaths in the United States each year. This makes health care facilities bigger killers of Americans than anything else, except cancer and heart disease. Doctors, nurses and other health professionals are responsible for killing more American each year than car accidents, guns and terrorists…combined.

Put another way, 10 percent of all deaths in the United States are due to medical mistakes. The following is a list of some of the more common types of medical errors, especially those that lead to medical malpractice lawsuits.

#1: Failed Diagnosis

A failed diagnosis (or misdiagnosis) is one of the leading causes of medical malpractice cases. Misdiagnosis can occur when the doctor fails to notice the threatening health condition in a patient or mistakes a harmful condition for a one that is not harmful. A failed diagnosis is common with a variety of health problems such as cancer, pulmonary embolism, infection and heart attacks.

A failed diagnosis can occur for a variety of reasons. First, it can be because the patient does not present textbooks symptoms. Second, the doctor may feel pressure to avoid “unnecessary” testing or medical procedures.

For example, let’s say you have a patient that presents symptoms that suggest they may have pneumonia. But it’s cold and flu season and the doctor wants to avoid an unnecessary x-ray when all the patient could have is a bad cold. So instead of calling for an x-ray, the doctor sends the patient home with the instructions to drink plenty of fluids and get some rest.

It turns out the patient had pneumonia and dies from it because they didn’t get antibiotics fast enough. The doctor didn’t mean for this to happen. The doctor avoided that x-ray because their boss was under pressure from the insurance company to not “overtreat” patients. Unfortunately, this doctor overcorrected and failed to provide enough treatment.

Third, the doctor can be negligent because he or she isn’t paying attention to the patient or doesn’t properly read the patient medical records.

#2: Mistakes with Medications

Medication mistakes are common because they’re extremely easy to make. Misreading the handwriting on a medical chart, confusing decimal points when dosing (and giving 10mg instead of 1.0mg, for instance) and confusing when the patient last received a dose (resulting in a double dose or a skipped dose) can cause severe problems and easily result in medical malpractice.

#3: Defective Medical Device

The human body is a fantastic and complicated machine. And as great as our medical knowledge is, we only know a small fraction of exactly how the body works. You know how we cringe and gasp when we read or hear about medical treatments from hundreds of years ago involving bloodletting or cutting holes in the skull to let out evil spirits? A few hundred years from now, you can almost guarantee that people will look back at some of today’s treatments with the same level of disgust and surprise.

Because we know so little, our attempts to create artificial replacements for the human body don’t always work. For example, using special metal alloys for hip replacements is leading to a lot of patients suffering from metallosis or metal poisoning. This occurs when tiny bits of metal rub off and go into the surrounding tissues and bloodstream. The human hip is a simple ball and socket joint, yet medical device designers have so much trouble replicating it artificially. This difficulty often leads to defective medical devices.

#4: Mistake During Surgery

Surgery is a risky and complex procedure where a variety of things can go wrong. People sometimes come out of an operation with a medical tool or sponge still inside them. Or maybe they have the wrong leg or arm amputated. Or an anesthesiologist makes a mistake with the patient’s reaction to a particular type of anesthesia. And almost all of these mistakes are completely preventable. For example, some doctors place an “x” on the limb that they will remove. But other doctors place an “x” on the limb that will stay and does not receive an amputation. It’s easy to see how there can be confusion. It’s not that hard to create a standard protocol for amputations when training doctors, but for whatever reason, many doctors don’t receive this in their education.

#5: Injuries During Childbirth

Childbirth-related injuries are unfortunate and should be rare, but they’re not. So many things can go wrong during seemingly routine childbirth. And to complicate matters, doctors and nurses have to worry not just about the mother, but the unborn or recently born child as well.

Do You Need to Learn More About Medical Malpractice?

You can find out more about medical malpractice cases by contacting our skilled attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

Medical insurance fraud commonly comes in the form of kickbacks.

Health services make up a large portion of the American economy, so medical insurance fraud is a common occurrence. Kickbacks are one of the most common forms of illegal behavior in the healthcare setting, but why is this the case? And what are kickbacks, anyway? Read on to find out.

What Are Kickbacks and How Do They Work?

A kickback is similar to a bribe in that one party will pay another party for improper benefits. Looking at an example is the best way to understand what a kickback is.

In a hypothetical healthcare setting, let’s say you have the patient, the patient’s primary care physician, the patient’s insurance company and a doctor who focuses on treating arthritis (we’ll call this doctor “John”). Now let’s assume the patient suffers from joint pain and goes to see his primary care physician. After an examination, the primary care physician believes the patient might have arthritis and refers the patient to Doctor John. The patient sees Doctor John and receives medical treatment. Along the way, the patient’s insurance company pays each doctor for the medical services they provide.

In a hypothetical involving a kickback, the patient’s primary care physician examines the patient. But instead of referring the patient to Doctor John, refers him to Doctor Bob. In return for referring the patient to Doctor Bob, the primary care physician receives a payment from Doctor Bob as a “reward” for sending him a new patient. In this example, the payment Doctor Bob sends to the primary care physician is a kickback.

Why Are Kickbacks Common?

One reason why kickbacks are so easy is that they’re easy to hide. Looking back at the above example, Doctor Bob and the primary care physician could be great friends who spend a lot of time together, perhaps playing golf once a month. During each of these golf games, Doctor Bob puts a roll of unmarked $20 bills in the primary care physician’s golf bag when no one is looking.

Unless the physician tells someone about this kickback, there will be almost no way to identify or trace those unmarked bills. Do you think the primary care physician is going to record the cash in the office business ledger or report it to the IRS as taxable income? The answer is no. An individual can easily hide a few hundred dollars per month of ill-gotten gains by simply using the cash for ordinary purchases. In fact, the primary care physician’s spouse probably won’t even know about it.

But one of the biggest reasons why kickbacks are so common is the nature of the healthcare system in the United States. Before a patient can see a doctor who focuses on a particular area of medicine, they need a referral. In other words, if a patient wants to see Doctor B, they must first see Doctor A. That doctor will give them a referral to see Doctor B.

In a perfect world, Doctor A will always refer patients to the best doctor, whether it’s Doctor B, C or D. Who Doctor A ultimately chooses is a judgment call. Doctors may not be able to provide a plausible reason to explain why they choose to refer a patient to one doctor and not another. This means it’s very easy to set up a situation for kickbacks.

Kickback Coverups

The only difficult part is covering up the kickback itself. As long as the kickback is small, it can probably remain hidden. But healthcare in the United States is expensive. With so much money flowing in and out of hospitals, doctor’s offices and clinics, it’s hard to keep track of it all. On top of that, the medical and financial records created from just one doctor’s visit are immense. Anyone would have trouble sorting through to catch a kickback scheme in action.

This is especially true in cases where a person has numerous medical procedures and bills or is in under medical care for a long period of time. Think of a person who undergoes cancer treatment, then spends several months in hospice before their death. That could be a good example of a case where unscrupulous providers could bill much more than they actually should.

In many situations, only an individual with a very detailed understanding of the financial operations of a healthcare facility can identify a kickback scheme. This is why whistleblowers are so important to stop kickbacks.

Looking for Additional Information about Fraud Related to Medical Insurance?

Despite the historical number of Medicare fraud arrests, more are set to come.

According to Modern Healthcare reporter Lisa Schencker, “Federal officials announced Thursday the largest coordinated, criminal Medicare fraud takedown—and the first large-scale effort to focus on Medicare Part D fraud—in the history of the U.S. Justice Department.

Over the last three days, the Medicare Fraud Strike Force has unveiled charges against 243 individuals across the country accused of falsely billing $712 million to Medicare in a number of separate schemes, said U.S. Attorney General Loretta Lynch. Those charged include 46 doctors, nurses and other licensed medical professionals.”

Of those arrested, more than 44 have been charged with fraud related to Medicare’s drug benefit program – Medicare Part D.

HHS Inspector General Daniel Levinson said costs in Medicare Part D reached $121 billion last year. “Our focus on Medicare Part D continues because more than 41 million Americans depend on that program, and its integrity must be protected,” Levinson said.

Law firms, like Health Law Partners, are starting to see a lot of fraud enforcement in the pharmacy area.

Medicare Part D More Difficult to Prosecute

Since Medicare Part D payments are capitated, instead of being fee-for-service, prosecuting in this area can be more difficult to prosecute than other areas of Medicade, according to Patrick Burns, co-director of the Taxpayers Against Fraud Education Fund.

Tony Maida, a former deputy chief of the administrative and civil remedies branch of HHS’ Office of Inspector General, also noted in a statement that the announcement Thursday “was packaged together by the government to create a high level of media and public exposure, as well as for a deterrent effect.”

Types of Charges Against the 243 Individuals

In this latest federal effort to crack down on fraud, the 243 individuals accused were charged with a variety of crimes including “conspiracy to commit healthcare fraud, violating the anti-kickback statute, money laundering and aggravated identity theft in areas including home healthcare, psychotherapy, physical and occupational therapy, durable medical equipment and pharmacy fraud.”

Who’s Investigating These Cases?

Medicare Strike Force teams from the Fraud Section of the Justice Department’s Criminal Division as well as U.S. attorney’s offices around the country are prosecuting and investigating these cases.

Bottom line: Medicaid pays the same amount for a Midwife as for an Ob-Gyn. Thus, some hospitals have a financial incentive to push even the high-risk patients to use Midwives rather than doctors. Unfortunately, this is happening at considerable risk and sometimes serious damage to patients.

$100 Million Lawsuit Filed

$100 Million federal law suit was filed against Indiana University Health and 2 associated medical organizations, Healthnet and MDWise. Allegations state “Contrary to their carefully crafted image of offering compassionate care for the indigent, two of the largest healthcare providers in Indianapolis put poor, pregnant women and their newborn babies at risk with a fraud scheme designed to increase revenues, regardless of the law or the risks to the most medically-fragile patients.”

A doctor at the hospital filed a complaint after what she saw there. Dr. Judy Robinson is the former medical director at the hospital. “I’m filing this lawsuit because of the abysmal care I witnessed these people receiving. And, after approaching IU Health, nobody would do anything.” Robinson pointed out that patients who should have received monitoring during their pregnancy didn’t receive the monitoring. “There was little to no physician involvement in the obstetrical care of these high-risk patients.”

Under the state Medicaid reimbursement rules, “Nurse midwives may not provide services to members with medically high-risk pregnancies. However, according to the lawsuit, lower-cost nurse midwives handled high-risk patients, in violation of the Medicaid regulations.

To make it worse, the hospital filed false-claims with the state and federal government for doctor services the patients never received. The hospitals are using midwives but getting reimbursed for using doctors.

Hospitals around the country have been accused of violating the false claims act. Children’s Hospital in D.C. is among them.

The allegations against Children’s Hospital

Children’s Hospital, Children’s National Medical Center Inc. and it’s affiliated entities, collectively known as CNMC faced claims of violating the False Claims Act. They are accused of submitting false claims reports and other applications to the Department of Health and Human Services (HHS) and to Medicaid programs in Virginia and the District of Columbia.

Violating False Claims Act Raises Health Care Costs for Everyone

“The false reporting alleged in today’s settlement deprived the Medicare Trust Fund of millions of taxpayers’ dollars,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department’s Civil Division. “Such conduct wastes critical federal health care program funds and drives up the costs of health care for all of us.” “The integrity of federal health care programs depends on honest and accurate reporting from the hospitals and other health care providers that receive hundreds of billions of tax dollars every year,” said Acting U.S. Attorney Vincent H. Cohen Jr. of the District of Columbia. “This settlement demonstrates our commitment to defending the integrity of the system and ensuring that taxpayer money goes to meet the most critical health care needs. We will continue to work with whistleblowers like the former employee who came forward in this case to battle waste, fraud and abuse that fuel the skyrocketing cost of health care.”

The settlement Agreement

Children’s Hospital agreed to pay $12.9 million in a settlement agreement. According to the settlement agreement, in two distinct ways, CNMC misstated information on cost reports and applications. The HHS and Medicaid programs used the false information to calculate reimbursement rates to CNMC. The United States contended that CNMC falsely reported its available bed count on its application to HHS’ Health Resources and Services Administration under the Children’s Hospitals Graduation Medical Education (CHGME) Payment Program. This program provides federal funds to freestanding children’s hospitals to help maintain their graduate medical education programs. Such programs train pediatric and other residents.

The United States further contended that CNMC filed cost reports which misstated their overhead costs. These false reports resulted in overpayment from Medicare as well as the Virginia and District of Columbia Medicaid programs.

Allegations against CNMC were filed by James A. Roark Sr., a former employee of CNMC, under the qui tam or whistleblower provisions of the False Claims Act. Under the False Claims Act, a private citizen can sue on behalf of the United States and share in any recovery. The United States is entitled to intervene in a False Claims Act lawsuit, as it did in this case.

From the $12.9 million settlement, Mr. Roark will receive $1,890,649.98.

In May 2009, the Attorney General and the Secretary of Health and Human Services announced the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative. This was done in efforts to combat health care fraud. The two departments are working together to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of their most powerful tools is the False Claims Act.

$24.3 billion has been recovered through False Claims Act cases since January 2009. More than $15.3 billion involves fraud against federal health care programs.Please note: This particular matter was handled by the U.S. Attorney’s Office of the District of Columbia with assistance from the Civil Division’s Commercial Litigation Branch and the HHS’ Office of Inspector General. The case is United States ex rel. Roark v. Children’s Hosp., et al., No. 1:14-cv-00616 (D.D.C.). The claims resolved by the settlement are allegations only, and there has been no determination of liability.

Are Doctors Relying on Pharmaceutical Companies to Pay Their Salaries?

More and more evidence seems to indicate that pharmaceutical companies are funneling money into the pockets of doctors who regularly prescribe their medications. This makes many people wonder whether they really need the medications they take, or if they are helping their physicians pay for their cruises, homes, and fancy cars.

The Startling Figures

According to an analysis performed by Modern Healthcare using an Open Payments database regarding Medicare Part D information, some 400 doctors prescribed more than $1 million worth of drugs in Medicare’s Part D prescription program. Of those 400 doctors, 23% received some sort of financial kickback from the drug manufacturer, whether in the form of consulting fees or other perks. As an example, a neurologist in Saginaw, Michigan named Dr. Gavin Awerbuch billed Medicare for more than $6.4 million worth of Subsys, a drug designed to help cancer patients fight pain, in 2013. The Justice Department indicted him last year for the fraudulent prescription of unnecessary medications.

Other Guilty Parties

Dr. Awerbuch is not the only party guilty of receiving money for prescribing medications. Dr. Vallerie McLaughlin, a University of Michigan cardiologist, prescribed nearly $5 million worth of Tracleer to Medicare recipients in 2013. This made her the sixth-highest prescriber of a single drug. What’s more, the manufacturers of that drug, Actelion Pharmaceuticals, a Swiss company, paid her $40,491 that year in clinical consulting fees, meals, and travel. Is that merely a coincidence, or are physicians truly prescribing unnecessary medications just to line their pockets?

Is It Legal?

There is no law that prevents pharmaceutical companies from rewarding doctors who regularly prescribe their medications. However, the drug makers cannot simply write the physicians checks for a job well done. Instead, they pay “consultation fees” to the doctors, which is nothing more than a clever way for the physician to earn a handsome kickback simply for prescribing a popular medication. Often, these fees include things such as luxurious meals, travel accommodations, and more – and sometimes even for the physician’s family, too.

What Does This Mean for Medicare Recipients?

Does this mean that Medicare recipients should be wary of every single drug they are prescribed? In some cases, yes. Although there is no proof that doctors across the country continue to prescribe medications to people who do not need them just to get financial kickbacks, it is happening – and it has been proven in some cases. Medicare recipients who receive prescriptions should carefully question their physicians to determine whether the drug is truly necessary. What’s more, obtaining a second opinion is also an option. Patients should do their own research and assist in determining whether medications are helpful or not necessary at all.

It is certainly sad that physicians who swore oaths to “do no harm” would prescribe their patients to take potent medications, often with severe side effects and the potential for addiction, even when those drugs are not necessary, just to earn some extra cash. It means that consumers must be on their toes, questioning their healthcare teams in times of sickness and health alike.

Pharmaceutical companies claim that the tremendous costs of prescription drugs are due to the sheer amount of research and development that goes into creating them. However, there is more to it than that. Pharmaceutical companies have one primary goal: maximizing the value of the company to shareholders. Often, maximizing that value equates to Americans paying exorbitant prices for their prescription medication – and some of these medications keep people alive.

How It Works

Big-name pharmaceutical companies across the globe are jacking up the prices of necessary prescription medications for no other reason than to increase revenue. While the pharmaceutical industry is like any other in that a little competition is healthy for the end users of the medications, many companies have taken things to extremes. A company may buy a medication that it sees as undervalued, then raise the price by 100%, 200% or even as much as 500%. Aside from this, companies put a high price tag on new treatments and regularly raise the prices of older medications, too. While the shareholders may be happy about these changes, the people who need their medications to stay alive are often swimming in debt.

Valeant Leads the Industry in Price Hikes

The Canada-based company known as Valeant is perhaps the key player in the industry price hikes. Since early 2011, the company has raised the prices on its medications by at least 20% some 122 times. More recently, on February 10 of this year, the company purchased the rights to a pair of life-saving heart medications known as Isuprel and Nitropress. The day following the acquisition, Isuprel’s price rose 525% from $215.46 to a jaw-dropping $1,346.62 for a one-milliliter vial. Nitropress jumped 212% from an original price of $257.80 to an astonishing $805.61 for a two-milliliter vial.

Other Companies Following Suit

Another prime example is the acquisition of Cadence Pharmaceuticals by Mallinckrodt PLC. Mallinckrodt purchased the company in order to gain the rights to Ofermev, a pain injection they believed was significantly undervalued. Three months later, the price of the already expensive injection jumped 2 ½ times to $1,019.52 for 24 doses. Horizon, another common pharmaceutical company, purchased the rights for a pain tablet known as Vimovo from the well-known AstraZeneca in 2013. Horizon sold Vimovo for the first time on Jan. 1, 2014 at a price 597% more than the original cost, which was $959.04 for 60 tablets.

Even generic drug prices are rising. Doxycycline, the most commonly used malaria treatment in the world today, has increased from an average price of $20 for 500 tablets to a whopping $1800 for the same amount. The drug is readily available in other countries for $40, which is a testament to corporate greed in the North American pharmaceutical industry. These prices not only take a huge toll on the average consumer, but they drive up the costs of health insurance programs, too.

Sixteen Hospitals Violate False Claims Act to the Tune of $15.69 Million

According to the US Justice Department, 16 hospitals across the country will repay the federal government nearly $15.79 million for claims submitted to Medicare for services deemed unreasonable or unnecessary. This is one of the largest violations of the False Claims Act to date.

Between the years of 2015 and 2013, the 16 above hospitals allegedly billed Medicare for Intensive Outpatient Psychotherapy, or IOP services, which are programs designed to treat individuals with serious mental disorders, that they knew were not billable. According to the claim, these hospitals billed Medicare for unqualified IOP services. According to current law, hospitals may only bill Medicare for services under certain conditions. In this case, the patients’ conditions did not qualify for IOP, staff failed to track patients’ progress properly, the patients did not receive the right level of treatment, or individualized treatment plans were not the first course of action as per Medicare’s guidelines.

The Impact on Consumers

With millions of dollars lost each year due to false and fraudulent claims like these, it is no wonder that the costs of healthcare continue to spiral out of control. Millions of people in the US rely on Medicare, a program for senior citizens and the disabled, to help them cover the enormous costs of healthcare. Due to false claims like these, the costs of healthcare are on the rise and Medicare covers less than ever before. Seniors and disabled persons who are already struggling to make ends meet must purchase expensive supplementary plans and pay exorbitant prices for many lifesaving prescription medications.

Whether the 16 hospitals above knew they were committing fraud when they submitted the claims remains unknown. However, one thing is certain: hospitals and medical centers like these need stricter guidelines for claims submissions. The Medicare program’s guidelines are indeed difficult to follow at times, but doing could save consumers tens of millions of dollars every year on the cost of insurance premiums alone.

A recent judgement against Jackson-Madison County General Hospital in Jackson, Tennessee means that the hospital will pay $1,328,465 to make up for improperly billing Medicaid and Medicare for the placement of unnecessary cardiac devices. The whistleblower in the case, Dr. Wood D. Deming, received a share of the settlement.

The Hospital’s False Claims

From January 2004 to December 2011, Jackson-Madison County General Hospital performed dozens of unnecessary cardiac procedures on patients for the sole purpose of collecting payments from Medicaid and Medicare. Federal law only allows hospitals reimbursement for medically necessary procedures. According to Edward L. Stanton III, the United States Attorney for the Western District of Tennessee, “Billing Medicare for cardiac procedures that are not necessary or inappropriate contributes to the soaring costs of health care and harms patients.”

Blowing the Whistle

Dr. Wood D. Deming raised the allegations under the qui tam (whistleblower) provisions of the False claims Act, which allows private citizens with knowledge of fraud to act on behalf of the government and share in the recovery. As such, Dr. Deming is entitled to his share of the settlement amount, which topped out at well over one million dollars. However, at this time, the claims are only allegations and liability has not yet been determined.

Improper Placement of Stents and Cardiac Procedures

The hospital’s allegations include improperly and unnecessarily placing stents, performing angioplasties and catheterizations, and using expensive ultrasound imaging when no medical need existed. This not only helped the hospital rack up costs that Medicaid and Medicare would later reimbursed, but it also put dozens of patients in danger. Unnecessary medical procedures carry risks of infection and bleeding, so the hospital exposed these patients to a host of unnecessary risks all in the name of corporate greed, according to Dr. Deming’s claim.

Understanding Cardiac Stents

A cardiac stent is a mesh tube surgically placed inside of the coronary arteries to keep them open. Often, in coronary artery disease, a coating of plaque lines the arterial walls, which presents a great risk for heart attacks and other complications. Not all patients with coronary artery disease require stents, however, but the Jackson-Madison County General Hospital placed them in patients when no medical need existed. Often, these procedures were followed or preceded by angioplasty (balloons placed inside the arteries), catheterization, and various types of imaging. This is a very invasive procedure, and one that many patients at the hospital just did not need, according to the whistleblower.

Patients already experience a great deal of anxiety and distress when dealing with heart problems like coronary artery disease. They should not have to worry about the competency of their doctors and health professionals. Thanks to whistleblowers like Dr. Deming, cardic patients at Jackson-Madison County General Hospital can breathe a sigh of relief.